Month: February 2016

As an internal medicine resident, a large chunk of my time is spent consulting other services to obtain their expert opinions. Sometimes, these consult requests are honored. Sometimes not. Equal parts frustrating and awe-inspiring, denying a consult is something of an art.

Here is a beginners guide to dodging consults: how to avoid doing your actual job, and letting someone else handle it. A guide to shirking your responsibilities, responsibly:

1. Master the technicalities of the order placement.

Internal Medicine: Hey, consulting you guys for suspicion of schizoaffective disorder. History of bipolar, but they’ve been off their meds for a while and they’ve had episodes of psychosis.

Psychiatrist: Wait, so is this a consult for schizoaffective or for bipolar?

Internal Medicine: Well, that’s why we’re consulting you. We’re not exactly sure.

Psychiatrist: You said schizoaffective, but the consult order said bipolar!!!

[whooping and high fives heard over the phone]

Internal Medicine: ….yeah, but…

Psychiatrist: If you want to consult us about shizoaffective, you’ll have to cancel that order and put in a new one, but we don’t take consults after 2 PM!

[The distinctive pop of a champagne cork is heard over the phone]

 

2.  Question. Everything.

Internal Medicine: Hey, we’ve got a woman in her late 40s with 1 day of RUQ pain, febrile, white count, D bili of 5, and alk phos 900. History of gallstones. You guys mind taking a look at her? Ultrasound shows pericholecystic fluid.  I’m pretty confident this is cholecystitis.

Surgery: Is that so?

Internal Medicine: …I think so.

Surgery: What’s her baseline alk phos? What type of pain is is it? When was her last CT? Who diagnosed these gallstones? Is she really a woman? How febrile is she? How long has she had this pain for? Who did the ultrasound? Who won the democratic presidential nomination in 1924? When –

Internal Medicine: Wait, so are you going to see her?

Surgery: Call us back when you have more of the history.

 

3. The Tautological Defense.

Internal Medicine: Good afternoon, esteemed colleague!

Dermatology: What’s up?

Internal Medicine: It’s a guy with really bad stevens johnsons. I’m not too comfortable managing it, wondering if you could help with some recs.

Dermatology: So if it’s an emergency, the on-call resident usually just sees them in the ER.

Internal Medicine: OK, but the ER admitted them.

Dermatology:  Right, but we actually don’t see floor patients, just ER emergencies. If it’s a floor patient, we just schedule them in clinic as outpatient.

Internal Medicine: It’s really bad, dude.

Dermatology: But the ER didn’t call.

Internal Medicine: I know!

Dermatology: Exactly.

Internal Medicine: What?

Dermatology: We’ll see them in clinic on Tuesday.

 

4. Subtly undermine their credentials.

Internal Medicine: Hey, sorry to bother you guys, but we’ve got a COPDer who’s not responding to his nebs and is on a venturi now. We’d like you guys to take a look.

Pulmonology: Who is this?

Internal Medicine: Gen Med. I’m the intern.

Pulmonology: Where’s your upper level?

Internal Medicine: She’s in clinic all day today.

Pulmonology: Yeah, usually the upper level will just consult us directly.

Internal Medicine: But I went over the case with her, she asked me to consult you guys.

Pulmonology: Nice try, bud. I’ll be looking out for her call. Tomorrow.

 

5. The “I’m on your side.”

Internal Medicine: Hey, can y’all see this one today? It’s Jones, the 70 year old with prostate cancer and urethral strictures. Rising Creatinine. You saw him in clinic.

Urology: Hey, thanks for checking in.

Internal Medicine: Yeah. You guys gonna take him back to the OR?

Urology: Good question. I don’t know, man. My attending can be really weird with some of these soft consults.

Internal Medicine: What do you mean?

Urology: Trust me, I want to see them. Like I’ll even see them just by myself. But my attending has been super busy this week, and it seems like we just saw them in clinic, so you may have to hold off on the official consult until Monday. I know, man, it sucks, I know.

Internal Medicine: I see.

Urology: In my soul – deep down – I know that seeing them is the right thing to do. The moral clarity of your request shines brightly, as if a great, blazing  torch lit atop an echoing mountain of freedom. I stand with you. But I stand in silence.

Internist: …

Urology: Just consult on Monday.

 

6. And, if all else fails, use one of these lines:

• “He doesn’t sound that sick.”
• “We don’t generally get consulted for that.”
• “Did you consult IR?”
• “Something something evidence based.”
• “Let me call you back after this case – it may take a few hours.”
• “I’m just stepping out for a conference.”
• “I’m rotating off service tomorrow – it may make sense to just hold off on that consult for a few days. Thanks!”

 

The dim monitor atop the COW (Computer on Wheels) outside room 916 flickered to life after a few insistent mouse clicks. COWs are now a ubiquitous part of hospitals, since medical records have essentially all been digitized. I briefly reacquaint myself with the patient’s chart before I enter the room. I head over to “Notes.” Pain management checked in with adjusted morphine dose. Cards noted that the patient’s EF was diminished, and that they would be starting a diuretic drip. In neat 2 hour increments, nurses left notes about bowel habits, pain, and vitals. People are constantly logging in and out of the COWs, and I don’t begrudge it the few seconds it takes for the screen to turn on. Though essentially all hospital personal document their patient interactions electronically, sometimes I get the feeling the COW would rather just be left alone.

Of all the notes the COW displays, the most incongruous has to be the ones from the “clinical chaplains.” Hospitals employ religious leaders of most mainstream faiths to help those inclined navigate the uncertain terrain of severe illness. While I’m not particularly religious, I think it a kind and decent thing for hospitals to do. Discussions that help patients clarify their end-of-life goals, or even their life goals, are helpful. But it has always struck me as somewhat bizarre that notes from these chaplains are mixed in among those from doctors and nurses.

Cows and God have a bit of a history. Moses got very angry at the Hebrews for deciding to worship a golden cow while he was away getting the 10 commandments on Mount Sinai. Thought it was disrespectful. I have to think that Moses would be, at the very least, confused by our modern COW/God symbiosis. We don’t exactly worship COWs, but we come pretty close. Medicine depends on COWs these days. As any medical professional will tell you, if the hospital-wide EMR ever shuts down (which has happened to me several times), the result is Tower of Babel chaotic.

I find the notes left by clinical chaplains, rabbis, imams, and pastors incredibly strange. For one, I don’t think most patients even know about the existence of such notes. I suspect it might change the way patients interact with hospital clerics. I’m guessing Catholic confessionals would be very different if the priest were jotting down what he heard and storing it in a permanent online file.

The bigger, issue, though, is that these notes just don’t get read. It may be due to the template-based format that so many EMR notes take nowadays. I will often peruse these notes out of curiosity and see the same auto-filled sentences trotted out. “Counseling offered.” “Spiritual empathy employed.” “Affect brightened by encounter.” Chaucer this is not. What it also is not, though, is useful, especially when you are trying to find an actual medical note. This may seem trivial, but I have seen patients with no fewer than 10,000 total notes written about them over the course of their hospitalizations. It is hard enough to piece together what different medical teams plan to do to patients, even when talking face to face, without having to wade through rivers of unnecessary text.

Moreover, everything you’d want covered by a note in the medical chart from a pastor is already covered, elsewhere. Patients have facesheets that document their religious affiliations. Hospitals urge patients to consider end of life decisions and advance directives early in their stay. Trained, professional social workers and counselors are also always available. And if patients reach a decision about their treatment plan from a talk with a chaplain, it can always be communicated to doctors in person.

It’s been a strange few millennia for God. After guiding desert tribes as an alternating pillar of smoke and fire, smiting those who dared to touch his ark, and creating the entire universe, he now finds himself rather unceremoniously inserted between the “total urine output” and “pre-anesthesia checklist” notes on EMRs across the country. I think guidance from religious leaders is perfectly appropriate for the faithful, and I am happy to call clinical chaplains for my patients. But please, let’s keep those conversations between the patient and the pastor, and out of the medical record.

Sometimes in life, but more specifically during a medical residency, you have to stay up all night. As a kid, staying up all night could pretty much only be awesome. It meant:

• A sleepover* was happening
• A snow day was imminent
• The olympics were happening in some foreign country, and for that week you and your whole family became ice skating experts at 3 AM (“She’s nervous…I can just tell. Her axels seem way off base.”

*Sleepovers are basically raves for little kids. Except that the drugs are video games, the club was just the house with the best food (this was critically important – you had to know whose house had the real snacks, and whose house had the rice crackers and soy paste), the promoter was your friend’s older brother, and the owner was a shadowy authority figure upstairs, wearing a robe.

As we progress through life, the night becomes more necessary and less charmed. The night becomes less of a buffer against what you failed to do during the day, and becomes more of the prime working time. Homework happens at night. Ditto for test studying. Sometimes it is preferable to working during the day – you aren’t taunted by sunlight and the promise of a frisbee toss, or whatever it is that real humans with respectable work/life balances do in their spare time outside (Run? Catch fireflies in jars? Laugh giddily in cornfields?)

I’m now working at a hospital nocturnally for a few weeks. The dreaded “night float” rotation. I’m covering for the primary teams while they are sleeping. I’m keeping watch. I’m like Jon Snow at the Wall. I’m like Batman, if Batman were called for very mundane and routine bureaucratic hold ups (“Help! Batman! Our W2’s were filed incorrectly!”). Now, I’m being a little hyperbolic (obviously). You never know when you will be called for a code, or a rapid response, so you always have to be sharp. And awake. But you have to admit, it would be sort of funny if Batman were called to the scene, and it just turned out that someone needed Tylenol for a minor headache.

BATMAN, (in his ‘dark and scary’ voice, whispering into the ear of a frightened old man): TAKE TWO. YOU SHOULD BE ABLE TO GO TO SLEEP NOW. IF YOU NEED ME, FLASH THE BAT SIGNAL. OR JUST HAVE YOUR PHARMACY CALL MY OFFICE.

OLD MAN: Thank you, Bat-

FWOOOOSSSSSHHHHHHHHH

[The OLD MAN‘s window is open, curtains flapping. BATMAN is gone]

[Bewildered, the old man is about to take his medications, when-]

FWOOOOOOSHHHHH

BATMAN: AND DONT FORGET TO CLOSE THE WINDOW. YOU’LL CATCH A COLD.

What are the benefits of working at night? Honestly, this is tough, as it really does just make a lot of sense to not do things when it’s dark and to do things when it’s light. But here goes:

• It’s peaceful, in the sense that ghost towns are peaceful before all the weird paranormal stuff starts happening. Sort of like the movie Hancock, except that you aren’t as cool or productive as Will Smith in your spare time when everyone else has died. Seriously, he was like cracking jokes to himself, and still working out despite no one else being alive. What a go getter. Wasn’t he a god or something in that movie? I forget. If everyone else died I think I’d probably stop going to the gym.
• You are actually at home during the day, so if you need to do anything to function in modern society like buying clothes or food, coordinating repairs, or going to the dentist, you can do it**
• You get an incredible sense of victory going home at 7 AM. It just feels like you’re winning more than you should, like you’ve dominated everyone else who is waking up because you’ve just been doing more than they have. Of course, this is fleeting, as you then get mediocre sleep in a too-bright room, then have a raging headache, and then curse yourself for working a nocturnal job. But there is that initial feeling, which is cool.

**This is, however, at the expense of sleep, which makes it utterly not worth it.

OK, that’s all I’ve got. I’m really excited to get back to a normal schedule.